Medi-Pak Advantage: Frequently Asked Questions

1 Medi-Pak advantage : Frequently Asked Questions General Information: What medicare advantage product is Arkansas Blue Cross Blue Shield offering? Arkansas Blue Cross and Blue Shield has been approved by the Centers for medicare and Medicaid Services (CMS) to begin offering a medicare advantage Private Fee-For-Service product: Medi-Pak advantage . There are two plan options, Medi-Pak advantage MA-PD, which includes coverage for part D prescription drugs and Medi-Pak advantage MA which does not include coverage for part D prescription drugs. A Private Fee-For-Service (PFFS) medicare advantage product offers enrollees full benefits for covered services from any physician or provider eligible to participate in medicare and willing to accept the plan s Terms and Conditions of payment (see pages 19-30). A plan may offer a Network or a Non-Network PFFS product.

2 Arkansas Blue Cross began marketing Medi-Pak advantage to medicare beneficiaries on October 1, 2006 with an effective date of January 1, 2007. Which PFFS network option has Arkansas Blue Cross selected? Arkansas Blue Cross has chosen to offer a Non-Network PFFS product. Payment for covered services will generally be the medicare allowable, less any member cost-sharing amounts. In accordance with CMS guidelines, if a provider is aware the member is covered by a medicare advantage PFFS product, has reasonable access to the Terms and Conditions of payment, and chooses to render services to the medicare advantage PFFS enrollee, then the provider is bound by the plan s Terms and Conditions of payment. A provider is not required to render services to a medicare advantage PFFS enrollee. A provider s decision can be made on a patient-by-patient basis.

3 What is Medi-Pak advantage ? Medi-Pak advantage combines the benefits of medicare part A and B and includes additional services not covered by traditional medicare . A Medi-Pak advantage member is free to choose any doctor, specialist or facility that accepts the Medi-Pak advantage Terms and Conditions of plan payment. The Benefit Summaries are available on the Arkansas Blue Cross and Blue Shield web site and AHIN. Also, providers may call 1-866-390-3369 for benefit and eligibility information. Medi-Pak advantage : Frequently Asked Questions Page 2 of 11 Updated: October 22, 2007 How do providers identify a patient with Medi-Pak advantage ? Providers can obtain eligibility information by contacting 1-866-390-3369 and providing the member ID number. Eligibility information will also be available on AHIN for Arkansas providers. Note that responses to eligibility inquiries are not a guarantee of eligibility or payment and are subject to limitations (See Effect of Eligibility Inquiry Responses in Terms and Conditions for Med-Pak advantage , outlined at pages 19-30 of this newsletter).

4 How can an Arkansas Provider participate in the Medi-Pak advantage Program? Arkansas Blue Cross has chosen to offer a Non-Network PFFS product. Since this is a non-network product, providers do not need to enter into a PFFS contract with Arkansas Blue Cross. To be eligible to furnish care to a PFFS member, physicians, or other healthcare providers must be state licensed and have a medicare billing number or be eligible to obtain one. Institutional providers treating PFFS members, such as hospitals and skilled nursing facilities, must be certified to treat medicare beneficiaries. The provider must also agree to the plan s Terms and Conditions of payment. Where do providers find the Terms and Conditions of Payment? For a copy of the Medi-Pak advantage Terms and Conditions of payment, go to the Arkansas Blue Cross web site at , select the Provider page and click on the medicare link or call Medi-Pak advantage Provider Service at 1-866-390-3369.

5 What networks are attached to Medi-Pak advantage ? Arkansas Blue Cross has decided to offer a Non-Network PFFS medicare advantage product so there is no network. A member has full benefits for covered services by any qualified* provider that agrees to accept the Medi-Pak advantage Terms and Conditions of Plan Payment. *(Please refer to the Deeming Process and the Terms and Conditions outlined on pages 19-30 of this newsletter for more explanation of the applicable program Terms and Conditions.) Are there contracted laboratories? Medi-Pak advantage is a Non-Network PFFS plan. Members have full benefits for covered lab work performed at any medicare -approved lab that is willing to accept the Medi-Pak advantage Terms and Conditions. Medi-Pak advantage : Frequently Asked Questions Page 3 of 11 Updated: October 22, 2007 What is a deemed provider?

6 Any provider furnishing health services to an Arkansas Blue Cross Medi-Pak advantage member, except for emergency services furnished in a hospital, is deemed to have a contract with Arkansas Blue Cross for purposes of services to Medi-Pak advantage members if: 1. Services are covered by the plan; 2. The member is an enrollee of Medi-Pak advantage ; 3. The provider is aware the member is a Medi-Pak advantage enrollee prior to rendering services to the Member; and 4. Providers know the Medi-Pak advantage Terms and Conditions of payment or have reasonable access to the terms and conditions of payment. If a facility is considered deemed, then Arkansas Blue Cross will consider any facility-based provider as deemed. Does the provider have a responsibility to somehow notify the plan that he or she is deemed? No, there are no contracts to sign and no paperwork required to participate.

7 The provider simply needs to see the member s ID card to identify the individual as a Medi-Pak advantage member and file a claim for services. The provider should review the Terms and Conditions of payment referenced on pages 19-30 of this newsletter and available on the Arkansas Blue Cross and Blue Shield web site at If the provider renders care to the member and files a claim, that provider is deemed. A provider may choose to provide care to Medi-Pak advantage enrollees on a patient-by-patient basis and may stop scheduling appointments with enrollees at their discretion. What if a provider does not want to accept Medi-Pak advantage ? Providers who do not accept Medi-Pak advantage s Terms and Conditions should not provide services to a Medi-Pak advantage enrollee, except for emergency care. If the provider chooses to provide services, then they by default have agreed to our terms and conditions of payment and must bill Medi-Pak advantage for covered health care services.

8 The provider should collect the appropriate Medi-Pak advantage copays or coinsurance from the enrollee at the time of service. The provider may at any time, on a patient-by-patient and visit-by-visit basis, decide that they do not want to treat a Medi-Pak advantage enrollee. What if a provider does not want to accept Medi-Pak advantage but the condition is an emergency? In such cases, claims should be filed to Arkansas Blue Cross (Arkansas providers) or the providers local Blue plan (out of state providers). How will providers know when Terms and Conditions change? Any changes to the Terms and Conditions are posted on the Arkansas Blue Cross web site. Providers will be notified of changes through the Providers News. Providers can also receive information on the Terms and Conditions by calling Medi-Pak advantage Provider Service at 1-866-390-3369.

9 Arkansas Blue Cross and Blue Shield can provide information by phone, by mail, or by fax. Medi-Pak advantage : Frequently Asked Questions Page 4 of 11 Updated: October 22, 2007 Is it the responsibility of the physician/health care provider to check the Terms and Conditions? While Arkansas Blue Cross does not anticipate frequent changes to the Terms and Conditions, it is the provider s responsibility to understand the Terms and Conditions. Providers should check the Terms and Conditions as Frequently as necessary. Under the traditional medicare , hospital patients must fill out a MSP ( medicare Secondary Payer) questionnaire. Should hospitals implement this process for Medi-Pak advantage members? Yes, hospitals should have their patients fill out the MSP. Arkansas Blue Cross reimburses physicians or other health care providers and attempts to recover the money from any third party that might be liable after the fact.

10 Benefits: What are the benefits of the Medi-Pak advantage products? Medi-Pak advantage benefits include convenient copayments and no deductibles. In the Benefit Summary section, under Diagnostic tests, x-rays and lab services, it mentions the member being responsible for a copayment for each service. Does that mean that if a patient is seen for an office visit, chest x-ray, and a lab test, the member will be charged three copayments for the one visit? No, only one copayment per visit. If a member just has lab drawn, they will be responsible for the applicable laboratory copay. For advanced imaging (MRI, MRA, CT Scan and PET), performed in a physician s office, you pay coinsurance in addition to the office visit co-pay. For part B Covered Drugs received in a physician s office, you pay coinsurance in addition to the office visit co-pay.